Smartwatches & Biometrics for Personal Health Monitoring

Josh Piemontesi, Braden Siempelkamp, and Gordon Minaker

Disclosures

• Nothing to disclose.

• No potential conflict of interest.

• No companies paying us :(

Disclaimers

• We will be discussing exercise-related topics in this presentation. See your doctor first to see if you are cleared to exercise. We are not doctors.

• The nature of the presentation will involve discussing consumer health products. We will try our best to approach this in an objective and unbiased way.

• We are not experts in all fields.

Objectives

• Overview of Smartwatches & Biometrics

• Discuss Fitness monitoring

• Preventative health & wellness

• Specialized monitoring

• Potential Pitfalls

• Potential Best Uses

#V361

WWW.SLI.DO

What is a Smartwatch?

...Many definitions.

What is a Smartwatch?

• Smartwatch - Device that is worn that monitors and tracks biometric parameters (Macridis, 2018)

• Biometrics - relating to or involving the application of statistical analysis to biological data

• For our presentation, we will be referring to all devices worn on the wrist as being either a “smartwatch” or “wearable”

• Some examples of wearables:• Fitbit Charge 2• Garmin Vivoactive 3• Jawbone Up3• Apple Watch Series 3• Samsung Gear S3

Smartwatch Components

• Optical sensor• Heart rate

• Contact sensor• Skin temperature

• Altimeter• Altitude gain or loss

• GPS• Biking/running route and distance

• Accelerometer• Step count• worn/not worn state• Overall physical activity levels• posture

• Gyroscope• posture

Purpose of Smartwatches

• Support individuals in becoming more active and lesssedentary (little or no physical activity; e.g., sitting)• Decreased risk of chronic physical and mental health

conditions (Owen, 2010; Warburton, 2006)• Cardiovascular Disease, stroke, hypertension, depression, anxiety,

cancers, diabetes, etc.

• Recommended 150 mins of Moderate to Vigorous Physical Activity (MVPA) per week (Warburton, 2007)

How many Canadians meet the Physical Activity Guidelines?

Taken from: https://www.canada.ca/en/public-health/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/2016-health-status-canadians/page-13-what-influencing-health-physical-activity.html

Purpose of Smartwatches

• Specialized health monitoring• Blood sugar• Blood pressure• Heart attacks

Uses of Smartwatches in Personal Health Monitoring

• Number of steps

• Weekly MVPA mins

• Sedentary time

• Distance walked or ran

• Heart rate

• Flights of stairs

• Calories burned

• Sleep patterns

• Skin temperature

How many of you wear a smartwatch?

Smartwatch Use

(Statistica, 2018)

Smartwatch Use

• Danova, 2013:• Projected that 373 million units sold in 2020

• Gartner, 2015:• Projected that 500 million units sold in 2020

Gartner. 2015. “Wearable Technology beyond Smartwatches.” Available at: https://www.gartner.com/smarterwithgartner/wearable-

technology-beyond-smartwatches-3/ (last accessed March 11, 2018)

Danova, T. (2013), “Why the smart watch market is poised to explode as it draws millions of consumers into wearable computing”,

Business Insider, pp. 1-18, available at: http://www.businessinsider.com/global-smartwatch-sales-set-to-explode-2013-9 (accessed

March 11, 2018)

Local Smartwatch Use

• Study in Alberta (Macridis, 2018)• 18 years or older• 1215 participants• Comparison of Normal vs. Overweight and between regions

(Metro Edmonton + Calgary vs. Rest of province)• Leisure-time physical activity (LTPA) questionnaire • Sedentary Behaviour Questionnaire • Questions related to Physical Activity Tracking Devices

Local Smartwatch Use

RESULTS

• Significantly associated with Physical Activity Tracking Devices:

• Being female

• <60 years of age

• Having post-secondary education

• Meeting PA guidelines

• Being overweight/obese

What does this mean?

• People in Canada are interested! • There is a consumer bias. • There are barriers in using wearables.

• 37% <1 month• 35% 1-6 months• 27% >6 months

What do the people want?!

• Many barriers, but...• Perceived usefulness is the most significant variable for

consumers to adopt and accept wearable technology

• A more current framework...What do the people want?!

Quantified Self

https://www.youtube.com/watch?v=8wqC6ad1V_Q

Questions?

SMARTWATCHES, FITNESS, AND HEALTH

Getting a “STEP” ahead

- Smartwatches have ubiquitous function as a pedometer- Counts the number of steps

- Step counting is one of the most accurate features of smartwatches

Richardson et al., 2008, Annal. Fam. Med.

Smartwatches as Pedometers

How does it work?

- Changes in acceleration in various axial planes

- Tracks pattern of movement of swinging arm; used as a proxy for steps- Complex algorithm

What is the recommended number of steps per day?

a. 1000b. 5000c. 10 000d. 20 000

Smartwatches as Pedometers

- Most smartwatches have preset goal of 10 000 steps- What does this mean?

Counting Steps

It depends….

Smartwatches as Pedometers

- The effect of walking 10 000 steps (or any number) varies greatly- Dependent on duration, intensity, & distance

- Pedometer use has been shown to: - Increase physical activity

- Be associated with moderate weight loss (0.7-1.85 kg)- Over 4 wks to 1 yr period

- Have slight increases in cardiovascular performance

Richardson et al., 2008, Annal. Fam. Med.

Smartwatches as Pedometers

- There is more to a healthy lifestyle than 10 000 steps but step goals can help facilitate healthy lifestyle changes

Normal Heart Metrics

Heart Rate (HR)

- Beats per minute

Rhythm

- Should be regular (aka sinus rhythm)

Amplitude

- Size or strength of the pulse- Not currently monitored by smartwatches

Monitoring Heart Rate (HR)

- Resting HR: 60-100 bpm

- Maximum HR estimate:- 220 - age (men)- 226 - age (women)

- Changes throughout lifespan

- Elevated resting HR associated with increased risk of cardiovascular disease and mortality

Amer et al., 2014, Am. J. Cardiology

Who has taken their heart rate before?

Taking Your Own Heart Rate

1. Find your radial pulse2. Feel for the radial artery3. Count the number of beats in a set

time interval (20 sec)4. Multiply by 3 to get beats per

minute

Monitoring Heart Rate

- Smartwatch monitoring - real-time tracking- Use an optical sensor to monitor blood flow

- Accuracy varies depending on device- Most within 80-90% of actual HR- Chest strap > wrist monitoring

El-Amrawy et al., 2015, Healthcare Informatics Research

Monitoring Heart Rate

Fitness - track heart rate for aerobic vs anaerobic exercise

- Aerobic intensity- Light: 30-39% HR max- Moderate: 40-59% HR max- High: 60-85% HR max

- Useful for training and exercise- Jogging, walking, cycling, swimming, etc.

Monitoring Heart Rate

Health - general monitoring for healthy patients or patients with known heart conditions (cardiopathies)

- Stay within physician-recommended, safe HR thresholds during rehabilitation and exercise

Monitoring Heart Rhythms

There is more to the heart monitoring than just the rate

Monitoring Heart Rhythms

- There is more to the heart monitoring than just the rate

- Heart rhythm, or the regularity of the heartbeat, is an important variable

- Rhythm commonly assessed using an electrocardiogram (ECG)

What is an ECG?

- An ECG (or EKG), or an electrocardiogram, records the electrical activity of the heart

- Gives information on the structure and function of the heart

P

QRS

TAtria

Ventricles

Monitoring Heart Rhythms

KardiaBand by AliveCor

Monitoring Heart Rhythms

- FDA approval for ECG (EKG) sensor for apple watch (Nov. 2017)- Doesn’t mean it is a good device

- Pairs with smartphone application

- Can monitor abnormal heart rhythms (arrhythmias) including atrial fibrillation

What is Atrial Fibrillation?

- An irregular heartbeat (arrhythmia) due to rapid, irregular atrial contractions - “quivering”

American Heart Association; Canadian Heart & Stroke Foundation

Normal Atrial Fibrillation

Importance of Atrial Fibrillation

- Blood stasis in heart can lead to pooling and clot formation

- 1/3 strokes after 60 are caused by A-fib

- A-fib patients have 3-5 times greater risk of ischemic stroke

American Heart Association; Heart & Stroke Foundation

Smartwatch ECG Monitoring

- Back to the smartwatch ECG…. how well does it work?

William et al., 2017, Eur. Heart. J.

Smartwatch ECG Monitoring

- A-fib detection:- Good sensitivity (96%) and specificity (94%) for detecting A-

fib compared to physician-interpreted ECGs- n=52; 225 paired ECGs; mean age 68

- This means that the smartwatch ECG was able to accurately detect both the presence and absence of atrial fibrillation

William et al., 2017, Eur. Heart. J.

Smartwatch ECG Monitoring

- Accurate detection compared to physician interpreted ECGs- 96% of ECGs were interpretable by physicians- 85% symptom-rhythm correlation (Newham et al., 2017)

- Pts. recorded when they were having symptoms

- Patients found device easy to use & lessened anxiety about A-fib

Newham et al., 2017, JAFIB

Smartwatch ECG Monitoring

Drawbacks

- Device is expensive (~$200) and requires a subscription for full range of features ($99/yr)- Limited accessibility to user

- Current studies limited by small sample size and potential bias

- Cannot replace current diagnostic standards but may complement as a tool to monitor patients with known A-fib or arrhythmias

Smartwatch ECG Monitoring

Apple Smartwatch Study

- Partnered with Stanford Medicine

- Via “Apple Heart Study” app, - Data is collected on irregular rhythms

- Users notified if A-fib detected

- Free consult with study doctor and ECG for monitoring

Smartwatch ECG Monitoring

Implications

- Exciting technology and may have future implications in monitoring of patients with heart problems

- May allow for rapid treatment of patients experiencing A-fib

Sleep Tracking

• Sleep disorders seriously affect quality of life

• Insomnia associated with impairments in daytime

functioning (Baglioni, 2013)

• Polysomnography is used for sleep monitoring (Kuo, 2017)

• Limitations of polysomnography (Kuo, 2017; Schute-Rodin,

2008)

• Must be in lab setting

• Electrodes and wiring

• Expensive equipment

Sleep Tracking

• Wearables (actigraphy) in sleep research and sleep medicine

• Measures movement, activity, and sleep

• Several algorithms proposed; each device has its own

measurement characteristics (Tilmanne, 2009; Jean-Louise,

2001; Sazonov, 2004)

• Validation and reliability studies required

• Studies have established this in infants, children, and

adults (Sadeh, 2011; Domingues, 2014; Ustinov, 2013)

• Biggest issue is detecting wakefulness within sleep periods

(Kuo, 2017)

What about validity and reliability for individuals with sleep-related disorders?

Sleep Tracking

• Kuo et al. (2017):

• actigraphy recorder with low sampling rate

• 81 participants

• Polysomnography compared to proposed actigraphy

recorder

• Objective sleep measurements:• Sleep efficiency• Total sleep time• Sleep onset time• Wake after sleep onset

Sleep Tracking

• 22 subjects used to develop sleep-wake algorithm• 43 subjects with ‘good’ sleep + 16 subjects with ‘poor’ sleep

• <85% sleep efficiency• Demonstrated reliability using limited information to estimate

wake-sleep stages during overnight recordings

Circles = “good” sleep

Crosses = “Poor” sleep

Line = Represents linear relationship

Closer to line = more accurate

measure (approximates

polysomnography)

Sleep Tracking

• Limitations for this study:• Unable to classify light sleep, deep sleep, and rapid eye

movement• Involuntary body movements could be misclassified as a

wake stage• Subjects with a long quiet-wake interval can be

misclassified as sleep

• Potential use for:• In-home screening• Evaluation of sleep• Measurement and tracking with treatment

Weight Loss

• Tracks calories burned (energy expenditure) via accelerometer algorithms

• Can use in conjunction with phone calorie tracking applications (e.g., MyFitnessPal) and body weight scale

• Calories in, calories out

Weight Loss

Weight Loss

• Stanford University School of Medicine researchers (May 2017) looked at energy expenditure of 7 devices (Apple Watch, Fitbit Surge, Samsung Gear)• 31 women and 29 men• Compared energy expenditure to gold standard

• Most accurate device off by 27%• Least accurate off by 93%

OTHER HEALTH PARAMETERS

Monitoring Blood Pressure

• Omron BP Monitor• FDA Approved

• Accuracy: +/- 3 mmHg or 2%

• Hypertension is the “silent killer”• Diagnosis is most accurate when

home blood pressure monitoring is used.

• Trends in BP can be useful• Physician review of data

Monitoring Hypertension

Diabetes

• Monitoring Glucose levels• Less invasive than current options?• Continuous glucose monitoring vs. on-demand• Newer models anticipated to be release soon; 10-day wear.

Falls in the Elderly

• Many apps.• Often used in conjunction with sensors

In smartphone.

• Can notify family.• Reduces fears of falling.• Accuracy not well known.

Epilepsy

• “Neutun” Software

• Medication Reminders

• Journal Log

• Notifies family during emergencies.

Heart Monitoring

Respiratory Diseases

• No good current options on market.

Support Networks

• Online Communities• Fitness• Diseases

• Physician Review

• Family Oversight

EVALUATING SMARTWATCHES

Accuracy and Validity

Reliability

Privacy and Security

Accuracy and Validity

- Devices are marketed under premise that they will improve health & fitness

- But majority of manufacturers provide no empirical evidence- Reliant on external institutions for proper evaluation

Accuracy and Validity

Steps > Distance > Physical Activity > Energy Expenditure > Sleep

Evenson et al., 2015, J. Behavioural Nutrition and Physical Activity

Accuracy and Validity

Heart Rate

Wang et al., 2017, JAMA Cardiology

Accuracy and Validity

- In medicine, we only perform a test if we believe it will be useful

- With wearables, patients will be able to monitor themselves constantly

- This will increase the amount of false positive and false negative results

Reliability

- An effective medical tool must be reliable

- A number of pitfalls plague smartwatches in regards to reliability

Reliability

Limited Battery Power

- Reported issue in many studies- Battery life variable; 2 - 7 days with use

- Speculated that power consumption will only increase

Reeder et al., 2016, J. Biomedical Informatics

Reliability

Watch Placement

- HR not collected when sensor is not in contact with skin

- Variations in HR even with skin contact

- Detection difficulties with hand-limited activities (biking) or tasks with high levels of wrist action (washing hands)

Kamdar et al., 2016, Pac. Symp. Biocomput.

Reliability

Data Quality

- Data must be interpretable to be useful- Gaps in data due to:

- Charging- Short breaks- Missed data

Kamdar et al., 2016, Pac. Symp. Biocomput.

Reliability

Interdevice reliability

How consistent are two of the same devices?

- High interdevice reliability for steps, distance, and energy expenditure

- High variation between devices when sleeping- Evaluated when wearing two devices

Evenson et al., 2015, J. Behavioural Nutrition and Physical Activity

Privacy & Security

• What are your concerns?

Privacy & Security

• Data Ownership• Insurance Companies• Personal Safety - especially in children• Employee Monitoring• Local vs. Cloud data storage

Privacy & Security

• Data Ownership• Insurance Companies• Personal Safety - especially in children• Employee Monitoring• Local vs. Cloud data storage

Smartwatch Summary

Today we have discussed the many applications of smartwatches

Future applications are exciting but caution should be used when using smartwatches for medical purposes

- Further research and validation is required

Currently, smartwatches cannot replace standard healthcare but may be complementary

Acknowledgments

Thanks to Dr. Gair & Let’s Talk Science for letting us put on this talk

Thank You!

• Questions?